Evaluation of the Effects of E-Learning on Nurses’ Behavior and Knowledge Regarding Venous Thromboembolism

Background: Continuing medical education (CME) is an integral part of nursing professionalization, which can be effective in the development of nursing behavior. E-learning can play an important role in CME programs. This study aimed to evaluate the effectiveness of an E-learning program in increasing the nurses’ knowledge and behavior regarding care for venous thromboembolism (VTE) patients. Materials and Methods: One-hundred nurses were selected via convenience sampling method and divided into E-learning and traditional education groups. All nurses had access to the Internet, as well as adequate Internet literacy. Each nurse in the E-learning group received three didactic files during the intervention (four weeks), which focused on the VTE risk assessment, methods of prophylaxis, prophylaxis guidelines, diagnosis, pharmacological and non-pharmacological treatments, and patient education. On the other hand, nurses in the traditional education group were taught traditionally by an expert lecturer, who used audiovisual materials for teaching. A pretest-posttest analysis and a checklist were used to evaluate the impact of interventions in the groups. Chi-square and Mann-Whitney tests were also used to analyze the data. Results: The comparison of knowledge level between the groups showed that E-learning is not superior to traditional learning methods. The mean changes in the nurses’ behavior was 3.16±1.49 in the E-learning group and 2.77±1.26 in the conventional education group. Statistical analysis showed a significant relationship between the score changes and E-learning. Conclusion: Integration of E-learning in CME programs, besides attendance of traditional courses, can be an effective learning method. We suggest that future studies compare the effects of these methods.

CME, based on needs assessment, can improve the learning outcomes (2). It is an essential part of nursing professionalization and can be helpful in the nursing practice development. Studies have shown that web-based teaching is as effective as conventional teaching methods in CME for nurses (3). It seems that CME programs are the most important area of E-learning due to several reasons.
First, the population requiring CME is distributed widely in different geographical regions. Second, not all people in the community have the same amount of time for learning.
Third, people's educational needs can be different, depending on their geographical and occupational status.
E-learning has been adopted in nursing as an appropriate alternative to traditional learning (5).
Generally, E-learning is considered an inexpensive and effective approach, which can overcome many problems, such as shift work exhaustion, low motivation, family involvement, lack of replacement employees, and interference of CME programs with work (6). E-learning programs are also suitable for nurses, as they can resolve problems, resulting from the nurses' inability to attend traditional courses because of shift schedules. In this comparative study, we aimed to compare E-learning with traditional education methods for the development of nurses' knowledge and behavior regarding venous thromboembolism (VTE). E-learning, as an emerging phenomenon, can overcome some of the traditional education barriers and provide accessible education and flexible learning. It is widely accepted that advances in information technology (IT) and learning methods have provided opportunities to create interactive, affordable, efficient, flexible, and learnercentered E-learning environments (7). E-learning, as a positive reaction to IT challenges in the academic setting, is characterized as follows: 1) Separation of time and/or space between the teacher and students, between the students themselves, and between the students and educational resources; 2) interactions between the teacher and students, between the students, and between the students and educational resources by means of one or more media, especially the Internet; and 3) a process of teaching and learning, not limited to the immediate time and/or place (8).
E-learning has been promoted as a cost-effective and convenient method, facilitating lifelong learning. It has several advantages over traditional learning, especially by enabling learning anytime and anywhere. In this method, students have access to online materials, regardless of time and place. They can also reflect on the learning materials and their responses and work at their own pace, regardless of their race, sex, disability, or appearance (9). Moreover, E-learning offers opportunities for students to preview and practice the materials. Studies also suggest that students are highly satisfied with online learning (10). Moreover, the multi-session use of online resources may lead to the reinforcement of E-learning (11).
While E-learning has many advantages, it is important to consider its disadvantages, as well, which include little or no in-person contact with faculty members, feeling of isolation, steep learning curves of navigation systems, problems with technology use, need for students' active involvement in the learning process, and increased lead time required for feedback to the assignments (12). In this regard, a review study by Cook et al. demonstrated that use of E-learning or Internet-based education has positive effects on the knowledge, skills, and behaviors of healthcare professionals, as well as patient outcomes (13).
Also, a recent study (14) revealed that online learning has many benefits for busy professionals, particularly due to the ease of access and use. knowledge about avian influenza in a CME program (17).
They found that web-based teaching is as effective as traditional teaching in nursing CME programs.
Moreover, a review study by Lahti et  Al-Hameed et al. recommended a CME educational program to improve the use of VTE prophylaxis (19). Their study revealed that appropriate VTE prophylaxis for patients, who developed VTE during hospitalization, increased significantly after a hospital-wide CME program, and the rate of hospital deaths associated with VTE tended to decrease after the CME program. Similar biomedicine studies have also shown the advantages of E-learning systems in professional educational programs (5,16,20).
Comparison of the knowledge and skills of physicians before and after attending traditional and electronic CME courses showed that E-learning is an effective approach for deep learning (21). Moreover, a more recent study on the use of an online E-learning system for nurses in delirium care showed that an E-learning course on delirium had significant effects on the nursing staff's delirium care for older patients. This study found a significant increase in the knowledge of delirium after nurses completed the Elearning program (22).
Generally, it can be difficult to increase the nurses' motivation and participation in their own education and skill development. The five most important factors, preventing nurses from participation in CME programs, include work commitments, domestic responsibilities, time constraints, scheduling of CME activities, and cost of the programs, as confirmed in previous studies (23). E-learning is a powerful tool, which can overcome these obstacles and help nurses become active and responsible contributors to their own education. According to our pilot study and the mean comparison formula, a sample size of 48 subjects per group was measured. Considering a 10% sample attrition, a total of 53 nurses were enrolled in each group. The inclusion criteria were as follows: 1) nurses with a bachelor's degree or higher; 2) no history of participation in an E-learning or CME program on VTE; 3) willingness to participate in the study; 4) access to the Internet; and 5) adequate Internet literacy. On the other hand, the exclusion criteria were lack of participation in the educational sessions for the traditional education group and failure to receive E-mail messages for the E-learning group.
Random available sampling was used to select the samples. The subjects had the right to withdraw from the study at any time. The hospital wards were located in four separate buildings. Fifty-three nurses were selected randomly from the wards in the northern area of the hospital for the traditional education group, and 53 nurses were randomly selected from the wards in the southern area of the hospital for the E-learning group. At the beginning of the study, each group consisted of 53 nurses.
However, during the study, three nurses from the traditional group and three nurses from the E-learning group were excluded due to lack of participation in the educational sessions and absence from the posttest. Moreover, the designed checklist was used to evaluate the nurses' behaviors before and after the intervention in both groups. Before starting the educational intervention, the nurses' behavior and attitude toward VTE were observed carefully to evaluate their background practice regarding VTE. One month after the intervention, their behaviors were evaluated using the same checklist. To encourage the nurses those who obtained scores above 15 for knowledge, and above 10 for behavior, received eight CME credits.

Data analysis
All statistical analyses were performed in IBM SPSS

Characteristics of the study sample
One-hundred nurses participated in the CME program.
As can be seen in Table 1

Changes in behavior
The results showed that the mean behavior score of the E-learning group increased from 3.64±0.82 before the program to 6.84±1.58 after the program. On the other hand, in the traditional education group, the mean score increased from 3.50±0.64 before the program to 5.90±1.12 after the program (behavior score was calculated out of 20) ( Table 2). The mean change of behavior score was 3.16±1.49 in the E-learning group and 2.77±1.26 in the traditional education group. The statistical analysis showed a significant relationship between the score change and type of education. Overall, changes in the behavior of the Elearning group were greater than the changes in the traditional education group (Figure 2).  Also, we found that E-learning is more effective than traditional methods in improving the learners' behavior.  (4,18,26). Also, online CME learners received regular text messages, containing an overview of the key messages of the session. These messages, as well as the multi-session use of online resources, might have led to learning reinforcement in E-learning (11).

Limitations
This study had some limitations. First, since we implemented the first E-learning program in Masih Daneshvari Hospital, and the technological infrastructure was not advanced enough, the nurses had some problems using the Internet. Second, the short duration of the followup (one month) was not adequate to obtain reliable results.
Finally, analysis of nurses' skills and performance was limited due to time constraints.